Authorization to Release Health Information

Expires upon one time release

Patient Information:

Please forward/release my health information to:

Conner Family Health Clinic

211 W. Matthews Street, Suite #102

Matthews, NC 28105

Phone: 704-708-4301.                    Fax: 704-708-4389

The information below is requested by this patient. (Check Box: Patient Medical Information Needed)

This authorization shall be in effect until the information has been forwarded as requested.

Patient Information

I understand that my treatment will not be conditioned on signing this authorization and that I have the right to refuse to sign this authorization. I understand that information disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

I understand that I have the right to revoke this authorization by sending a written notification to the address below and that a revocation is not effective if the information has already been disclosed but will be effective going forward.

I understand that I have the right to inspect or copy the protected health information as described in this document. I can do this by written notification to Conner Family Health Clinic.